Case ReportUse of Awake Flexible Fiberoptic BronchoscopicNasal Intubation in Secure Airway Managementfor Reconstructive Surgery in a Pediatric Patientwith Burn Contracture of the Neck

Tolga Totoz,1 Kerem Erkalp ,2 Sirin Taskin,3 Ummahan Dalkilinc,2 and Aysin Selcan2

1Department of Anesthesiology and Reanimation, Nisantasi University, Istanbul Safak Hospital, Turkey2Department of Anesthesiology and Reanimation, Health Sciences University,Istanbul Bagcılar Training and Educational Hospital, Turkey3Department of Anesthesiology and Reanimation, Health Sciences University,Istanbul Haydarpasa Sample Training and Research Hospital, Turkey

Correspondence should be addressed to Kerem Erkalp; keremerkalp@hotmail.com

Received 11 April 2018; Accepted 20 September 2018; Published 21 October 2018

Academic Editor: Pavel Michalek

Copyright © 2018 Tolga Totoz et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Although the use of awake flexible fiberoptic bronchoscopic (FFB) intubation is a well-recognized airway management techniquein patients with difficult airway, its use in smaller children with burn contractures or in an uncooperative older child may bechallenging. Herein, we report successful management of difficult airway in a 7-year-old boy with burn contracture of the neck,by application of FFB nasal intubation in a stepwise approach, first during an initial preoperative trial phase to increase patientcooperation and then during anesthesia induction for the reconstructive surgery planned for burn scars and contractures. Ourfindings emphasize the importance of a preplanned algorithm for airway control in secure airway management and feasibilityof awake FFB intubation in a pediatric patient with burn contracture of the neck during anesthesia induction for reconstructivesurgery. Application of FFB intubation based on a stepwise approach including a trial phase prior to operation day seemed toincrease the chance of a successful intubation in our patient in terms of technical expertise and increased patient cooperation andtolerance by enabling familiarity with the procedure.

1. Introduction

Secure airway management is crucial in reconstructivesurgeries involving patients with burn contracture of theneck [1, 2], while it is a challenge to the anesthesiologistdue to anticipation of difficult intubation with likelihoodof profound anatomical variation that may not readily beappreciated even during preoperative assessment [1–3].

Awake intubation is considered a safe approach in theairway management of a patient with burn contracture of theneck, particularly for cases presenting with the combinationof difficult laryngoscopy as well as difficult mask ventilation[2, 4, 5]. Hence, awake endotracheal intubation remains at thetop of the decision algorithm in the recently updated practice

guidelines for management of the difficult airway by Amer-ican Society of Anesthesiology (ASA), although no specifictechnique or tool has been suggested for accomplishing thistask [6].

Fiberoptic-guided tracheal intubation remains the goldstandard for pediatric difficult airways and is an essentialskill for anyone practicing pediatric anesthesia [7–10]. Awakeflexible fiberoptic bronchoscopic (FFB) intubation is a well-recognized airway management technique in patients withdifficult airway [4], while its use in smaller children withburn contractures or in an uncooperative older child may bechallenging and necessitate inhalational induction technique[2, 11, 12].

HindawiCase Reports in AnesthesiologyVolume 2018, Article ID 8981561, 5 pageshttps://doi.org/10.1155/2018/8981561

2 Case Reports in Anesthesiology

Being a cornerstone of safe anesthetic practice in manag-ing patients with identified difficult airway, awake intubationenables prevention of the disastrous consequences of apotential “cannot intubate and cannot oxygenate” scenario,while necessitating a preplanned strategy for intubation andpatient preparation regarding explanation of the proposedprocedure, sedation, administration of antisialogogues, andregional anesthesia of the airway [2, 4].

Herein, we report successful management of difficultairway in a 7-year-old boy with burn contracture of the neck,by application of awake FFB nasal intubation in a stepwiseapproach, first during an initial preoperative trial phaseto increase patient cooperation and then during anesthesiainduction for the reconstructive surgery planned for burnscars and contractures.

2. Case Report

A 7-year-old Syrian boy with war-related burn injury wasreferred to our hospital for reconstructive surgery for burnscars and contractures on his face, neck, and body. A con-sultation with anesthesia department was held by plastic andreconstructive surgery clinic for the preanesthesia evaluation.Patient was conscious and oriented on examination. He hadsevere scar contractures involving neck, face, anterior chest,and both shoulders leading to restricted mouth opening, noneck extension, and stooped posture with chin and chestfused together by scars and the neck and head contracted inflexed position. The width from upper incisor to lower teethwas approximately 15 mm and Mallampati class was 3, whilethyromental and sternomental distance could not be evalu-ated due to neck and head being contracted in flexed position.Cardiac, thoracic, and laboratory investigations revealed nor-mal findings. Detailed history of the patient obtained fromthe parents by the help of a translator revealed that the childhad been posted for the reconstructive surgery in anotheruniversity hospital, while the operation was cancelled dueto failure to maintain mask ventilation even after pain reliefand induction of anesthesia. The previous anesthesiologisthad given two attempts after induction of anesthesia butfailed at intubation. Then child was awakened. The dayafter, he was transferred to our hospital for difficult airwayapproach and the operation. Awake FFB nasal intubation wasplanned because of the past history of “cannot intubate andcannot oxygenate” scenario. The necessity and details of theprocedure were explained to the patient and his family by thehelp of a translator. After a 6-hour fasting period, the patientwas admitted to our intensive care unit (ICU), accompaniedby a family member and translator. Following the routine(NIBP, HR, StO

2) monitorization (Nihon Kohden, Japan),

patient has been informed again about the details and steps ofthe procedure with the help of the translator. Premedicationand sedation were not applied because of the patient’s status.During the initial trial phase, nasal drop of xylometazoline0.1% was instilled for vasoconstriction in both nostrils. Threepuffs of 10% lidocaine were implemented for topical anes-thesia. Through a nasal cannula, oxygen was administeredat 5 L/min through the left side. Tip of the fiberoptic bron-choscope (FOB, 2.8 mm, Karl Storz-Endoskope, Germany)

was inserted into the contralateral nostril. Endoscopy wasperformed. When the vocal cords were visible, the trialprocedure was ended. It was explained to the patient and hisfamily that the same procedure would be repeated on the dayof surgery as followed by intubation and induction of generalanesthesia. On the day of operation, two days after the initialtrial, patient was taken to the surgery room and monitored(Infinity Delta Drager, Lubeck, Germany) routinely (NIBP,HR, SatO

2). A nasal drop of xylometazoline 0.1%was instilled

for vasoconstriction. Three puffs of 10% lidocaine spray wereimplemented for topical anesthesia. It directly sprayed ontothe mucosa of the mouth, pharynx, and tongue. Through anasal cannula, oxygen was administered at 5 L/min throughthe left nostril. Endoscopy was performed through the rightnostril. Two ml of 2% lignocaine was sprayed through theFOB on to the glottis after the vocal cords were seen. TheFOB’s tip was then passed into the trachea through thelaryngeal opening and was stopped just above the carina.Lubricated 5.0 nasotracheal tube was railroaded over theFOB. After three ventilations, position of nasotracheal tubewas confirmed by the FOB. Successful tracheal intubation hadbeen achieved while maintaining spontaneous ventilationand was monitored by capnography. Propofol, fentanyl, androcuronium were used for induction of general anesthesiavia intravenous route and maintained with remifentanil 0.1𝜇g/kg/min and sevoflurane in oxygen (Primus workstationDrager, Lubeck, Germany). The operation lasted for approx-imately four hours. The contractures on neck and left axillawere released and graft was placed.The intraoperative coursewas uneventful. The patient was extubated after completerecovery of consciousness, adequate spontaneous breathing,preventive reflex, and muscle strength [13] (Figure 1).

3. Discussion

Our findings indicate feasibility of awake FFB nasal intu-bation in a 7-year-old boy with burn contracture of theneck accompanied with restricted mouth opening, no neckextension, and fixed flexion deformity, during anesthesiainduction for reconstructive surgery for burn scars andcontractures.

Restricted mouth opening, Mallampati class (>2), lack ofneck movement, and inability to evaluate thyromental andsternomental distance due to flexed position of neck and headin our patient signify a difficult airway and emphasize thatcertain airway assessment parameters useful in evaluationof a difficult airway are not applicable in patients with burncontracture of the neck [2, 14].

Given patient's history of difficult tracheal intubationand/or mask ventilation, our findings support the consider-ation of alternative rather than standard means of securingan airway as a first-line option in patients with face andneck contracture [1, 2]. Our findings also emphasize theutility of awake FFB nasal intubation in postburn pediatricpatients with fixed flexion deformity related nonalignmentof the oral, pharyngeal, and laryngeal planes for intubation[2, 4], provided that measures to enable sufficient patientcooperation were implied.

Case Reports in Anesthesiology 3

Figure 1: Patient’s perioperative images.

Although FFB is considered to be the probably most com-monly used tool for awake endotracheal intubation in devel-oped countries [4, 15], in accordance with its considerationas the least traumatic and most efficient alternative to directlaryngoscopy in patients with postburn scar contractures ofthe neck [1, 16, 17], there are other tools available such asFastrach intubating laryngeal mask airway (ILMA) [4, 18].

In a past study on comparison of safety and efficacyof ILMA and FFB in awake tracheal intubation of patientswith difficult airway, FFB was reported to be associatedwith significantly lower rate of success on the first attempt(58% versus 95%) along with need for multiple attemptsin 42% of patient [4]. However, ILMA has been associatedwith limitations in certain patients such as those with veryrestricted mouth opening who need a nasal intubation andthose aged <10 years or weighing less than 30 kg due tounavailability of pediatric sizes [4, 19, 20]. Hence FFB seemedto be most reasonable option for management of difficultairway via awake intubation in our patient given his youngage and the need for a nasal intubation.

FFB intubation with topical anesthesia of the upperairway in an awake or sedated patient is considered byanesthesiologists as the ultimate, safe, nonsurgical techniquein difficult airway management [21]. Although, FFB intuba-tion can cause significant circulatory responses in healthyanesthetized children, the circulatory responses to flexiblenasal intubation are considered less frequent and shorter-term responses than those to flexible oral intubation [22].

Hence, based on history of an unsuccessful attempt forintubation and mask ventilation under sedation or generalanesthesia in our patient, we preferred awake FFB nasalintubation with use of no sedative or anesthetic agent. While,from a physiologic perspective, children have higher rates ofoxygen consumption, significantly shortening the period ofapnea that can be safely tolerated [23], no hypoxia occurredduring the procedure in our patient given that oxygen wasapplied through the contralateral nostril.

Although application of fiberoptic tracheal intubationthrough the nasal route rather than the oral route is consid-ered likely to be more straightforward for clinicians with lessexperience using pediatric bronchoscopes [6], use of FBB in

awake intubation is considered to require significant trainingand experience to achieve a high success rate [4]. This seemsnotable given that successful outcome of an awake intubationis considered a net result of different factors includingappropriate case selection and good patient preparation tooptimize the patient's comfort and compliance as well astechnical expertise method of intubation [24].

Awake intubation has been advocated as the safest tech-nique to secure the airway in a cooperative patient for adifficult airway [12, 25]. In this regard, application of FFBnasal intubation based on a stepwise approach includinga trial phase prior to operation day seemed to increasethe chance of a successful intubation in our patient interms of improved technical expertise as well as increasedpatient cooperation and tolerability after familiarity with aprocedure limiting the handicaps of a translation-mediatedcommunication.

Our findings support that vigilance and preparednessis the key to success in the postburn patient with crucialrole of judicious preoperative airway and scar evaluation totimely recognition of anticipated difficulty with ventilation,intubation, or both in order to develop a preplanned strategyfor airway control [1, 2, 14].

Some anesthesiologists have also reserved videolaryn-goscopy (VL) for difficult pediatric airway according to thealgorithm [26]. On the other hand, FFB intubation is still thegold standard for anticipated difficult airway management inchildren. Use of VL might have been an alternative [27]. Likeour method, awake VL technique also may be considered inchildren

The limitation of our method is that we did not use short-acting sedatives/opioids, such as remifentanil or midazolamfor sedation in this case, because of detrimental effects,such as muscle rigidity, hypoxemia, respiratory arrest, orhemodynamic fluctuations requiring treatment [28], andketamine or sevoflurane administration during procedurebecause of awake FFB intubation effort.

In conclusion, our findings emphasize the importance ofa preplanned algorithm for airway control in secure airwaymanagement and feasibility of awake FFB nasal intubationin a 7-year-old boy with burn contracture of the neck

4 Case Reports in Anesthesiology

and fixed flexion deformity, during anesthesia inductionfor reconstructive surgery for burn scars and contractures.Application of FFB intubation via stepwise approach witha trial phase prior to operation day seemed to increase thechance of a successful intubation in our patient in terms oftechnical expertise and increased patient cooperation andtolerance via familiarity with the procedure. We would alsoemphasize the importance of preoperative demonstrationand explanation of fiberoptic procedure, which is somethingoriginal and probably resulted in key point for successfulmaneuver.

Additional Points

Highlights. (i) Use of awake FFB revealed successful airwaymanagement in burn contracture of neck. (ii) Preoperativetrial FFB seems likely to increase patient cooperation andtoleration. (iii) Awake FFB nasal intubation seems feasible inpediatric difficult airway management.

Consent

The necessity and details of the procedure were explained tothe patient and his family by the help of a translator. Awritteninformed consent was obtained from parents of the patientfor use of patient data for publication purposes.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

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